Professional Documents
Culture Documents
doi: 10.1093/bjaceaccp/mkv011
Advance Access Publication Date: 8 June 2015
Matrix reference
1D02, 2E02, 3A08
Ventilatory management
Trauma is a major cause of morbidity and mortality worldwide, Ventilatory management of patients with rib fractures begins
and the leading cause of death in the first four decades of life. with supplementary oxygen. This should be humidified to loosen
Rib fractures are very common and are detected in at least 10% secretions and help sputum clearance improving patient com-
of all injured patients, the majority of which are as a consequence fort. Nebulized saline may also help reduce sputum retention. Re-
of blunt thoracic trauma (75%) with road traffic collisions being spiratory physiotherapy can also be useful, but the patient’s
the main cause. The remaining 25% are due to penetrating injur- ability to cooperate will often be limited by discomfort.
ies. Rib fractures are associated with significant morbidity, with If, despite supplementary oxygen, the PaO2 cannot be main-
patients frequently requiring admission to the intensive care tained, continuous positive airway pressure can be useful.
unit (ICU), and mortality rates as high as 33%.1 Positive pressure will act to reduce atelectasis, reduce intrapul-
monary shunting, and will reduce the paradoxical movement
Pathophysiology of a flail segment, if present. However, it can be uncomfortable
This morbidity and mortality associated with rib fractures is for the patient and may make expectoration more difficult.
caused by three main problems: hypoventilation due to pain, im- Ultimately, if other measures fail, sedation and invasive ventila-
paired gas exchange in damaged lung underlying the fractures, tion may be necessary. This is extremely undesirable and should be
and altered breathing mechanics. avoided where possible in patients without other injuries. Pain
Pain associated with rib movement reduces the tidal volume management therefore plays a key role in managing these patients.
and predisposes to significant atelectasis. This can further lead to Once ventilated, early weaning from a ventilator is paramount.
retention of pulmonary secretions and pneumonia.
An injury severe enough to fracture ribs, especially if so sig-
Rib fracture scoring
nificant as to cause a flail segment, will invariably cause a sub- The number of ribs fractured correlates with the severity of the
stantial contusion to the underlying lung. The lung becomes injury and together with age, they are the most important
© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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26
Rib fracture management
determinants of morbidity and mortality.2,3 Four or more frac- scores 2. For ‘sides’, unilateral fractures scores 1 and bilateral 2.
tured ribs are associated with higher mortality rates and seven Age is factored into the equation due to the aforementioned in-
or more have a mortality rate of 29%.4 The presence of a flail creased risk of complications, with different age groups scoring
chest alone has a reported mortality rate of 33%, since the para- between 0 and 4.
doxical chest movement further inhibits effective ventilation.5 In a study by Maxwell and colleagues,7 they found the scoring
The elderly are particularly susceptible to rib fractures and the system did not have a strong statistical validity as a predictor, but
associated complications, with pneumonia rates as high as 31%.6 it was a useful screening tool to heighten awareness of increased
Ribs fracture more easily and are often a result of only moderate risk. We have used the scoring system as a decision-making tool
trauma. This is as a consequence of osteoporosis, cartilage degen- to decide on the appropriate level of analgesia required for each
eration, and reduced elasticity. Respiratory mechanics are affected patient (Fig. 1).
due to a reduced muscle mass, a weakened diaphragm, and
intercostal muscles, along with a loss of alveoli. These changes
culminate in a reduced lung volume, decreased lung function, Analgesia for rib fractures
and impaired gas exchange with a poor respiratory reserve.
All these alterations, along with other co-morbidities, make the The associated pain is notoriously difficult to manage, but effect-
elderly patient with rib fractures at increased risk of hypoventila- ive analgesia started promptly prevents hypoventilation, enables
tion, atelectasis, pneumonia, and subsequent ventilation. deep breathing, adequate coughing with clearance of pulmonary
With these factors in mind, Easter created a formula to deter- secretions, and compliance with chest physiotherapy. Overall,
mine which adult patients are at higher risk and therefore in this reduces secondary pulmonary complications, including atel-
need of a higher level of care:4 ectasis, pneumonia, respiratory failure, and the need for respira-
tory support.
Patients presenting to the emergency department after blunt
Rib fracture score ¼ (breaks × sides) þ age factor
chest wall trauma may require urgent intervention, including in-
tubation and ventilation, but others may show little or no respira-
‘Breaks’ is the total number of fractures to the ribs and not the tory compromise. However, pulmonary complications often only
number of ribs fractured, for example, two fractures in one rib become evident 48–72 h after the injury.
It is therefore imperative that effective analgesia is started Table 1 Local thoracic epidural regime
promptly, preferably in the emergency department upon admis-
sion, not just for analgesia and patient comfort, but also to try and Loading dose 0.25% bupivacaine, 7.5–12 ml
Infusion 0.1% bupivacaine+2 μg ml−1 fentanyl, 5–15 ml h−1
prevent the complications that ensue over the subsequent days.
Breakthrough Bolus infusion mixture, 5–10 ml, or
Opioids were previously the mainstay of treatment, but with
pain Bolus 0.25% bupivacaine, 5–10 ml
significant side-effects, including respiratory depression, de-
Consider bolus of epidural diamorphine 2–3 mg,
pressed cough reflex, and delirium; multi-modal analgesia is
once daily only
now more commonly used, which incorporates regional nerve
blocks and thoracic epidural analgesia.
Figure 1 is our current working rib fracture algorithm that in-
much down to the operator and local policy. Our local policy is de-
corporates Easter’s scoring system to help identify those patients
scribed in Table 1. The addition of opioids, for example, diamor-
at greatest risk for morbidity and mortality and provide an anal-
phine, can prove highly beneficial, especially in an inadequate
gesic pathway to most suit their needs.
epidural. However, number of ribs fractured, co-existing injuries,
age, co-morbidities, and haemodynamic status will all have an
Step 1: simple analgesics impact on the volume of local anaesthetic used, addition of
opioids, and the starting rate of the infusion. Throughout the dur-
The analgesia prescription for a patient should include regular
ation of the thoracic epidural, the extent of the block (both sen-
simple analgesia, for example, paracetamol, a weak opioid, a
sory and motor) need to be monitored and the patient requires
non-steroidal anti-inflammatory drug (if not contraindicated),
regular (4 h) nursing observations, including arterial pressure
and a strong opioid for breakthrough pain. If adequate analgesia
and pulse and oxygen saturations.
is achieved then the patient can be continued on this regime.
Although thoracic epidurals provide excellent analgesia for
the management of rib fractures, they are limited to a certain
Step 2: opioids population due to patient factors and side-effects. Many trauma
patients have other injuries which contraindicate the use of epi-
If the pain is not controlled with the interventions in Step 1, then
durals, or which prevent positioning for insertion.
i.v. morphine can be titrated to effect with slow boluses of up to
0.1–0.2 mg kg−1. Once adequate analgesia is achieved, a strong
opioid (e.g. a slow-release morphine sulphate or oxycodone) Contraindications6
can be added to the regular prescription in place of the weak opi-
oid in Step 1. Side-effects of strong opioids such as nausea and Absolute
vomiting and constipation need to be addressed with the rele- • Patient refusal
vant antiemetic and laxative prescriptions. • Spinal cord injury
• Epidural or spinal cord haematoma
• Thoracic vertebral body fracture
Step 3: i.v. patient-controlled analgesia • Spinal injury awaiting assessment
• Coagulopathy ( platelets <50×109 litre−1, INR>1.5)
If the pain remains uncontrolled, or multiple morphine boluses
are required, then a morphine i.v. patient-controlled analgesia • Local infection or sepsis
should be started, providing the patient can successfully operate • Allergy to local anaesthetic
one. The addition of gabapentinoids should be considered due to
Relative
their analgesic properties and opioid-sparing effects.
• Inability to position patient due to associated injuries
• Severe traumatic brain injury
Step 4: regional anaesthetic techniques • Unstable lumbar or cervical spinal fractures
and operative fixation • Anticoagulant therapy
• Platelet count 50–100 × 109 litre−1
Thoracic epidural • Hypotension
Epidural analgesia has become the standard of care when opioid • Hypovolaemia
analgesia is inadequate or initial presentation requires it, al- There are disadvantages to thoracic epidural analgesia. They are
though it is an underutilized resource. Patients with higher rib technically challenging to insert, with a risk of dural puncture or
fractures, multilevel or bilateral fractures, flail chests, intercostal spinal cord injury. Adverse effects include hypotension, and if
drains, and functional respiratory compromise secondary to pain opioids used, urinary retention and pruritus. Patients can de-
benefit most from epidurals.8 velop a motor block and are unable to mobilize with an epidural
Multiple retrospective reviews and prospective trials have de- in situ.
monstrated improved pulmonary function, including tidal vol-
ume and maximal inspiratory force, enhanced analgesia, with
overall better clinical outcomes when compared with treatment
Paravertebral block
with systemic opioids.8 The improved pulmonary function re- Injection of local anaesthetic into the thoracic paravertebral
duces the incidence of pneumonia, number of ventilator days, space produces unilateral sensory, motor, and sympathetic
and mortality, especially those sustaining five or more rib block. The spinal nerves are not initially bound by a fascial
fractures.2,9 sheath, therefore enhancing uptake of local anaesthetic. The
When performing a thoracic epidural to provide analgesia for paravertebral space communicates with the epidural space
multiple rib fractures, the vertebral level of insertion should medially and the intercostal space laterally, but with adequate
ideally be that of the middle fractured rib. Choice of local anaes- volume, the majority spreads caudally and cranially covering at
thetic and loading doses, along with the infusion regime, are very least five sensory dermatomes.10 One catheter can cover up to
six consecutive fractured ribs, but a second catheter can be in- and colleagues found a greater duration of action from superficial
serted for more than six levels, or for bilateral fractures, if a thor- placement.
acic epidural is contraindicated. The vertebral level of insertion
should ideally be at the height of the middle fractured rib. Indications/contraindications
Ensuring not to exceed the maximum local anaesthetic dose,
we recommend a bolus of 40 ml of 0.25% levobupivacaine, fol- Suitable for all rib fractures, there are very few contraindications
lowed by an infusion of 0.1% levobupivacaine at 5–10 ml h−1 via to inserting a serratus plane block, with patient refusal, allergy to
an elastomeric pump. The infusion can be continued for up to local anaesthetics, and local infection the only standard absolute
7 days. Multiple or bilateral blocks can be performed, but ensure reasons.
local anaesthetic doses are within safe limits. Relative contraindications are associated with distorted anat-
Evidence suggests that paravertebral blocks are as effective as omy making landmarks difficult to identify by ultrasound, for ex-
thoracic epidurals without many of the contraindications, com- ample, surgical emphysema, intercostal drain placement, and
plications, and side-effects seen with epidurals.11 A relatively previous surgery at the insertion site.
safe and technically easy procedure that is ideally performed
under ultrasound guidance, it can be inserted in the unconscious Recommended technique
patient. Sympathetic blockade is not seen when compared with
thoracic epidurals due to limited epidural spread. Importantly, Preparation
patients can also mobilize with a catheter in situ. Informed consent should be obtained from the patient, and the
block performed with a trained assistant in an area where full re-
suscitation equipment is available. Standard non-invasive mon-
Contraindications
itoring should be applied and an i.v. cannula inserted. Aseptic
Absolute precautions should be maintained throughout the procedure.
• Patient refusal
• Allergy to local anaesthetic
Procedure
• Local infection or sepsis
As described by Blanco and colleagues, the block is performed
Relative with the patient in the supine position and the arm abducted.
• Inability to position the patient Using a high-frequency linear ultrasound probe set between 6
• Transverse process fractures at the level of the intended block and 13 MHz, place the probe in the sagittal plane and identify
• Unstable vertebral fractures the fifth rib in the mid-axillary line. Latissimus dorsi and serratus
• Anticoagulated patients/deranged clotting anterior muscles are now easily identifiable overlying the fifth rib
(Fig. 3). The planes can be found between a depth of 1–2 cm from
the skin, with the thoracodorsal artery passing in the superficial
Complications
plane to serratus anterior (Fig. 2).
• Failure After local anaesthetic infiltration, using a 50 mm 18 G Tuohy
• Inadvertent epidural or intrathecal injection catheter needle, insert the needle in-plane superficial (recom-
• Epidural spread and hypotension mended and demonstrated in Figs 3 and 4) or deep to the serratus
• Pneumothorax anterior muscle (Figs 5 and 6). Inject local anaesthetic and con-
• Intrapleural injection firm good spread between latissimus dorsi and the serratus mus-
• Vascular puncture cle, or deep to serratus. Ensuring not to exceed the maximum
• Local anaesthetic toxicity local anaesthetic dose, we recommend a bolus of 40 ml of 0.25%
levobupivacaine. Immediately insert a catheter 2–3 cm into
the space, tunnel, and secure in place. Correct catheter place-
Serratus plane block ment can be confirmed by demonstrating further local anaes-
A regional anaesthetic technique first described in 2013 by Blanco thetic spread under ultrasound visualization. Commence an
and colleagues12 for surgery performed on the anterolateral chest infusion of local anaesthetic, again weight dependent, but 0.1%
wall, serratus plane blocks aim to provide anaesthesia of the
hemithorax. It has been used in patients with rib fractures as
an alternative to thoracic paravertebral blocks and thoracic
epidurals.13,14
Anatomy
The serratus anterior muscle originates on the anterior surface of
ribs 1–8 and inserts on the medial border of the scapula. A poten-
tial space exists both superficial and deep to the serratus anterior
muscle. The latissimus dorsi muscle lies superficial to serratus
anterior, with the ribs and thoracic intercostal nerves lying
deep to, but also piercing the serratus muscle. This therefore en-
ables the thoracic intercostal nerves to be blocked when injecting
local anaesthetic in the potential space around the serratus mus-
cle, providing analgesia to the anterolateral part of the thorax,
with paraesthesia from T2 to T9.12 Local anaesthetic can be infil-
trated either superficial or deep to serratus anterior, but Blanco Fig 2 Ultrasound probe and needle orientation.
Fig 3 Ultrasound image of a superficial serratus plane block. Fig 6 Good spread of LA is seen deep to SM, above ribs 4 and 5.
Complications
• Pneumothorax
• Vascular puncture
• Nerve damage
• Failure/inadequate block
• Local anaesthetic toxicity
• Infection
Fig 4 On injection of local anaesthetic (LA), good separation is demonstrated
between latissimus dorsi (LD) and the serratus muscle (SM).
Interpleural block
This has fallen out of favour as it provides suboptimal pain relief
for patients with rib fractures.11 Local anaesthetic can be in-
jected via the chest drain, however, before absorption, it can
drain out via the chest tubing. Large volumes are required and
with rapid absorption, local anaesthetic toxicity is a risk. The
distribution of the local anaesthetic is influenced by gravity
and therefore patient positioning may prevent the correct inter-
costal nerves being targeted leading to an inadequate block.
Blood or fluid in the pleural cavity will also dilute the local an-
aesthetic. Occluding the drain before and after injection can
cause its own complications and may not be clinically safe. In-
fection can be introduced into the pleural cavity and an empy-
ema can develop.
Intercostal block
Fig 5 Ultrasound image of a deep serratus plane block.
Although correctly placed intercostal blocks can be very effective,
levobupivacaine at 5–10 ml h−1 via an elastomeric pump is opti- providing effective analgesia for 4–24 h, reducing morbidity and
mal, and can be kept running for up to 7 days if no signs of infec- length of stay, they involve multiple injections with a risk of
tion. Bilateral blocks can be performed, but ensure the maximum pneumothorax and intravascular injection with every injection
dose of local anaesthetic is not exceeded. (http://www.trauma.org/archive/thoracic/CHESTflail.html). 11
Static and dynamic pain scores, along with incentive spirom- The risk of local anaesthetic toxicity increases with every injec-
etry and patient satisfaction, can confirm the adequacy of the tion due to its rapid absorption. Palpation to determine the ap-
block. propriate site for injection causes patient discomfort. Catheters
have been placed in the intercostal space which provides spread
of local anaesthetic to adjacent intercostal spaces providing anal-
Advantages gesia to several dermatomes.
• Technically easy and superficial block
• Performed with patients supine, therefore particularly useful
Operative fixation
when other injuries prevent patients rolling laterally or sitting Management of rib fractures by stabilizing the chest has been
to perform either a thoracic epidural or paravertebral block around for centuries, but has gone in and out of fashion.